NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. Which response would the nurse make to a client with schizophrenia who claims to be Joan of Arc about to be burned at the stake?
- A. ''Tell me more about being Joan of Arc.''
- B. 'We both know that you're not Joan of Arc.''
- C. ''It seems like the world is a pretty scary place for you.''
- D. 'You're safe here, because we won't let you be burned.''
Correct answer: C
Rationale: The nurse would say, ''It seems like the world is a pretty scary place for you.'' This response allows the nurse to understand the symbolism, reflect on and acknowledge the client's feelings, and help preserve the client's integrity. The statement, ''Tell me more about being Joan of Arc,'' validates the client's delusion and does not test reality. The statement, ''We both know that you're not Joan of Arc,'' rejects the client's feelings and does not address the client's fears of being harmed; clients cannot be argued out of delusions. The statement, ''You're safe here, because we won't let you be burned,'' is false reassurance; the nurse is agreeing with the client's false perceptions of reality, which is nontherapeutic.
2. Which activity would be most beneficial for a school-age client diagnosed with a chronic illness to enhance a sense of accomplishment?
- A. Wearing make-up
- B. Making up missed work
- C. Participating in sports activities
- D. Participating in creative activities
Correct answer: B
Rationale: Making up missed work is an essential activity that can help a school-age client diagnosed with a chronic illness feel a sense of accomplishment. By catching up on missed work, the child can regain a sense of control and productivity, which can be empowering during a challenging time. Wearing make-up is more related to personal grooming and self-expression, which may not directly contribute to a sense of accomplishment in this context. Participating in sports activities is beneficial for peer relationships and physical health but may not address the immediate need for accomplishment in the academic setting. Engaging in creative activities fosters cognitive development but may not directly address the sense of achievement associated with completing academic tasks.
3. In the care of a withdrawn, reclusive psychotic client, which goal is the priority?
- A. Establish trust
- B. Increase feelings of self-worth
- C. Solidify sense of identity
- D. Improve ability to socialize
Correct answer: A
Rationale: The priority goal in the care of a withdrawn, reclusive psychotic client is to establish trust. Trust is fundamental in building a therapeutic relationship, which is essential for effective care. Without trust, the client may not engage in therapy or interventions. Once trust is established, the nurse can then assess the client's feelings of self-worth, sense of identity, and ability to socialize. While these other goals are important in the overall care of the client, establishing trust forms the foundation for further progress in the therapeutic relationship and treatment.
4. Which nurse statement defines boundaries in the orientation phase of the nurse-client relationship when talking to a depressed client who has just been admitted to the psychiatric unit?
- A. ''Tell me about the relationship that you have with your mother and father.''
- B. ''Hello! I'm Nurse Andrea. I'll introduce you around and help you settle in.''
- C. ''What is the main thing that you would like to work on during therapy?'
- D. ''I understand that you have been depressed. What can you tell me about that?'
Correct answer: B
Rationale: In the orientation phase of the nurse-client relationship, setting boundaries involves establishing the nurse's role and responsibilities while maintaining a professional distance. Option B demonstrates a clear boundary by introducing the nurse and offering assistance with settling in, which is appropriate for the initial phase of building rapport with the client. Choices A, C, and D delve into personal or therapeutic topics that are more suitable for the working phase of the relationship when the client's goals and problems are being addressed. Asking about the client's family relationships (Choice A), therapy focus (Choice C), or delving into the client's depression (Choice D) would be more relevant in later stages of the therapeutic process, once trust and rapport have been established during the orientation phase.
5. The nurse notes bruises on the pregnant client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm which condition?
- A. Domestic abuse
- B. Hydatidiform mole
- C. Excessive exercise
- D. Thrombocytopenic purpura
Correct answer: A
Rationale: Domestic abuse is a serious concern during pregnancy as it can escalate, and the bruises on the face and abdomen may indicate physical violence towards the pregnant woman. Hydatidiform mole presents with symptoms like an enlarged uterus for gestational age, hypertension, nausea, vomiting, and vaginal bleeding, not bruises. Excessive exercise typically leads to cardiovascular or pulmonary issues, not bruising. Thrombocytopenic purpura and other bleeding disorders usually present with bruises and petechiae on various body surfaces, not just limited to the face and abdomen.
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